Recurring concern

Unsafe application of Mental Health Act detention safeguards to informal patients

First to latest report 27 Jan 2014 — 6 Feb 2026

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
5

What this concern includes

Includes failures in the Mental Health Act process for assessing, authorising, implementing or reviewing detention or restriction of informal patients, including staff understanding of detention powers, section 5(4) use, transition from informal status, lawful-authority checks and safeguards for people who are effectively detained.

What is not included
  • Excludes failures limited to Mental Health Act assessment recommendations or the timeliness of statutory assessment where detention-safeguards application is not the identified concern.
  • Excludes Deprivation of Liberty Safeguards authorisation, renewal or review failures unless the report also concerns the Mental Health Act detention-safeguards process for an informal patient.
  • Excludes general leave, absconding, security or observation failures where no Mental Health Act detention or lawful-authority issue is identified.
  • Excludes generic legal training or policy deficiencies not specifically tied to applying Mental Health Act detention safeguards to informal patients.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Mansoor Zaman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding

    Wider context from the report

    “1. The failure of nurses on the ward to instigate an authorisation under S.5(4) MHA 1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 2024. ”

    Source location

    Mansoor Zaman · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide ward staff with further refresher training on holding powers, emergency MCA use and related legal requirements.

    Verbatim wording from the response

    “24. That said, I was appraised of the oral evidence heard at inquest. The explanations provided by some (but not all) of the staff as to how section 5(4) or 5(2) are used were not in-line with the legal requirements set out in the MHA. This is a matter of concern to the Trust. Consequently, at the time of inquest, I requested that the ward staff undergo refresher training in relation to their holding powers. This took place on 25 February 2026. Within the next 6 months, the Associate Director of Mental Health Law is going to hold a further refresher session with the all the ward staff to include situations when the MCA may be used in an emergency. They will also update the rapid tranquilisation policy to ensure it restates this position with clarity.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the rapid tranquilisation policy to clearly restate the relationship between holding powers, consent and emergency alternatives.

    Verbatim wording from the response

    “24. That said, I was appraised of the oral evidence heard at inquest. The explanations provided by some (but not all) of the staff as to how section 5(4) or 5(2) are used were not in-line with the legal requirements set out in the MHA. This is a matter of concern to the Trust. Consequently, at the time of inquest, I requested that the ward staff undergo refresher training in relation to their holding powers. This took place on 25 February 2026. Within the next 6 months, the Associate Director of Mental Health Law is going to hold a further refresher session with the all the ward staff to include situations when the MCA may be used in an emergency. They will also update the rapid tranquilisation policy to ensure it restates this position with clarity.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 6 · response
    Published 12 February 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Section 5(4) powers were unavailable because a doctor’s immediate attendance had been secured.

    Verbatim wording from the response

    “17. In the present case, the immediate attendance of a doctor was secured. Therefore, section 5(4) powers were not lawfully available for the nurse to invoke.”

    Source location

    2026-0072 - Response from East London NHS Foundation Trust
    Page 5 · response
    Published 12 February 2026

    Open published response

  2. Surrey

    AI-generated summary

    Charne Nikita Petit · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Detention of patients in general hospitals without a section while awaiting a mental health bed

    Wider context from the report

    “(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed, because they cannot be placed under section unless a mental health bed is available. ”

    Source location

    Charne Nikita Petit · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Invest in new mental health units and community, crisis, and acute services to improve access and reduce avoidable admissions.

    Verbatim wording from the response

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.”

    Source location

    Response from NHSE
    Page 1 · response
    Published 26 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Direct systems to reduce average adult acute mental health ward stays and improve timely access to local beds.

    Verbatim wording from the response

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance continues this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards and in order to deliver more timely access to local beds.”

    Source location

    Response from NHSE
    Page 1 · response
    Published 26 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide recurrent funding to integrated care boards to recommission inpatient care in line with evidence-based therapeutic local models.

    Verbatim wording from the response

    “This is being supplemented by a further £42m recurrent investment from 2024/25 for all ICBs in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support”

    Source location

    Response from NHSE
    Page 2 · response
    Published 26 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Detention under the Mental Health Act in an acute hospital can occur only with the acute Trust’s agreement.

    Verbatim wording from the response

    “Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited.”

    Source location

    Response from Surrey and Borders Partnership
    Page 2 · response
    Published 26 September 2024

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Andrew Peter Wells · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to apply the Mental Health Act appropriately to informal patients who are effectively detained

    Wider context from the report

    “2. The expert witness also stated the Mental Health Act was not applied appropriately. Namely, whilst Mr Wells was technically an informal patient, the clinicians recognised that he would be detained if he tried to leave i.e. he was ‘de-facto’ detained without additional resources and safeguards applicable to a detained patient being put in place. The expert witness said ‘de-facto’ detention was contrary to the Code of Practice to the Mental Health Act and Mr Wells should have been detained. Therefore, my on-going concern is that the Trust’s clinicians are not applying the Mental Health Act appropriately. ”

    Source location

    Andrew Peter Wells · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Southampton and New Forest

    AI-generated summary

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Erroneous belief that informal patients cannot be detained when safety concerns arise

    Wider context from the report

    “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient training on Mental Health Act implementation for informal patients

    Wider context from the report

    “5.3 It was apparent that the nurses on the ward felt unable to use their powers under section 5(4) of the Mental Health Act 1983 to prevent patients from leaving the ward even when they had real concerns for the safety and welfare of that person and that they erroneously believed that informal patients were not detainable in such circumstances. The training they had received on the implementation of the Mental Health Act in relation to informal patients had not covered this aspect sufficiently. ”

    Source location

    Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. West Sussex

    AI-generated summary

    Maureen Leaver · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maureen Leaver, who had dementia and severe delusions, was admitted for assessment in July 2010 and later transferred to hospital with profound hypothermia. She died on 6 October 2010; the report identified concerns about inadequate medical supervision and systems for investigating and managing acutely ill elderly patients, as well as understanding of legal duties when changing her patient status.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of understanding of legal duties when transferring non-consenting patients from Section 4 MHA 1983 to informal patient status

    Wider context from the report

    “2. A lack of understanding of the legal duties imposed by the Mental Health Act 1983 and the Mental capacity Act 2005 when transferring patients who cannot consent to treatment from Section 4 MHA 1983 to being an informal patient. ”

    Source location

    Maureen Leaver · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026